Chapter 33: Anatomy

Neuroanatomy
Angiology
Myology
Arthrology
33
 ANATOMY
Neuroanatomy
1. Femoral nerve:
a. Formed from the ventral rami of lumbar nerve roots (L2, L3, and L4)
b. Divides into anterior and posterior division (the posterior division gives rise
to the saphenous nerve which supplies cutaneous innervation to the medial
leg and foot)

2. Sciatic nerve:
a. Formed from the ventral rami of lumbar and sacral nerve roots (L4, L5, S1,
S2, and S3)
b. The largest nerve of the body
c. Divides into its terminal branches, the tibial and common peroneal nerve
d. Supplies all musculature of the leg and foot (except 'for that supplied by
the saphenous nerve)

3. Common peroneal nerve (L4, L5, S1, S2):

a. One of 2 terminal branches of the sciatic nerve, and winds superficially
around the neck of the fibula
b. Gives off the sural communicating near the head of the fibula, which joins
with a communicating branch of the tibial nerve to form the sural nerve
c. Terminal Branches:
i. Deep peroneal nerve: This nerve runs with the anterior tibial artery
(laterally) in the lower leg to give muscular innervation to the EDL, EHL, TA,
peroneus tertius, EDB, and ends in the first interspace
ii. Superficial peroneal nerve: In the distal 1 /3 of the leg, the nerve pierces
the anterolateral intermuscular septum and deep fascia to become
cutaneous, and divides into 2 branches, the medial and intermediate dorsal
cutaneous nerves before reaching the ankle. This gives innervation to the
peroneus longus and brevis

4. Tibial nerve (L4, L5, S1, S2, S3):

a. The larger of the 2 branches of the sciatic nerve
b. Travels between the two heads of the gastrocnemius to leave the popliteal
fossa, descends along the back of the leg with the posterior tibial artery and
veins
c. The nerve lies medial to the blood vessels in the upper 1 /3 of the leg and
lateral to them in the lower 1 /3 of the leg d. The nerve supplies the
gastrocnemius, popliteus, tibialis posterior, FHL, and FDL
e. Terminates into medial and lateral plantar nerves at the level of the
lacinate ligament (prior to this, gives off medial calcaneal branch)

5. Sural nerve (L5, S1,S2):

a. Formed by union of medial sural cutaneous (tibial) and sural
communicating branch of the lateral sural cutaneous of the common
peroneal
b. Pierces the deep fascia to become cutaneous at the upper mid-calf region,
travels distally near the lateral side of the achilles with the small saphenous
vein, and passes forward below the lateral malleolus
e. Becomes the lateral dorsal cutaneous nerve on the lateral aspect of the
foot

6. Saphenous nerve (L3,L4):

a. This is the only nerve in the foot that originates from the lumbar plexus
(comes off the posterior division of the femoral nerve and is its longest
branch)
b. Travels with the greater saphenous vein along the medial side of the leg
c. It divides into 2 branches in the lower 1 /3 of the leg giving sensory
innervation to the skin of the medial ankle and medial side of the foot (it may
reach distally as far as the metatarsophalangeal joint)

7. Deep peroneal nerve (L4, L5, S1):

a. Travels with the anterior tibial artery and lies lateral to it in the foot
b. Divides into its terminal branches and passes into the dorsum of the foot in
the middle compartment
c. Its terminal branches are the lateral terminal nerve (passes across the
tarsal area to innervate the EHB) and the medial terminal nerve (to the 1st
interspace) where this divides into 2 dorsal digital nerves (2nd dorsal digital
proper nerve & 3rd dorsal digital proper nerve)

8. Superficial peroneal nerve (L5, S1, S2):

a. Primarily a cutaneous nerve with 2 terminal branches, the medial and
intermediate dorsal cutaneous nerves
b. Medial dorsal cutaneous nerve divides into a medial and lateral branch.
These supply the medial side of the hallux, lateral side of the 2nd toe, and
the medial side of the 3rd toe.
c. Intermediate dorsal cutaneous nerve divides into medial and lateral
branches. These supply the lateral side of the 3rd toe, medial side of the 4th
toe, lateral aspect of the 4th toe, and the medial aspect of the 5th toe

9. Lateral dorsal cutaneous nerve (S1, S2):

a. A continuation of the sural nerve below the ankle, and communicates with
the intermediate dorsal cutaneous nerve, and divides into 2 branches (one to
the lateral side of the 5th toe, and the other anastomoses with branch of the
superficial peroneal nerve)
10. Medial calcaneal nerve (S1, S2):
a. Last branch given off by the tibial nerve before dividing into medial and
lateral plantar nerves
b. It perforates the lacinate ligament and divides into anterior and posterior
branches (posterior branch supplies the heel)
c. The anterior branch continues distally into the plantar aspect of the foot,
where it anastomoses with the lateral calcaneal branch of the sural nerve
laterally, anastomoses with the saphenous nerve anteromedially and
anastomoses with the lateral and medial plantar nerves distally

11. Lateral Calcaneal Nerve (S1, S2):

a. Given off before the sural nerve goes around the lateral malleolus
b. Supplies the cutaneous innervation to the lateral aspect of the heel and
sensory innervation to the lateral proximal aspect of the plantar surface of
the foot
12. Medial plantar nerve (S3):
a. Larger of the 2 terminal branches of the tibial nerve running in the 3rd
compartment of the lacinate ligament
b. Enters the foot at the porta pedis and emerges from between the abductor
hallucis and FDL
c. Supplies the cutaneous innervation to the medial plantar aspect of the
midfoot, abductor hallucis, FDB
d. Its terminal branches are the 1st plantar digital nerve and 1st, 2nd and 3rd
common plantar digital nerves
]

13. Lateral plantar nerve (S2, S3):

a. Smaller of the 2 terminal branches of the tibial nerve, lying posterior to the
posterior tibial artery, eventually lying medial to the lateral plantar artery
with which it travels into the plantar aspect of the foot b. The nerve passes
through the porta pedis lying between the FDB and quadratus plantae.
Between the FDB and abductor digiti minimi the nerve divides into its 2
terminal branches, superficial and deep c. Superficial branch comes off the
main branch at the level of the 5th metatarsal and supplies the flexor digiti
minimi brevis, opponens digiti
minimi (when present), 3rd plantar interosseous, and 4th dorsal interosseous
d. Deep branch follows along with the lateral plantar artery between the 3rd
and 4th muscle layers (deep to the adductor hallucis and superficial to the
plantar interossei) and supplies the transverse/oblique heads of the adductor
hallucis, lateral 2 (or 3) lumbricales, and interosseous muscles of the 2nd and
3rd intermetatarsal space (2nd and 3rd dorsal, 1st and 2nd plantar), and 1st
dorsal interosseous

NOTE* The 1st and 2nd dorsal interossei receive additional innervation from
the deep peroneal nerve

Angiology
1. The arteries: Blood flows from the left ventricle of the heart, through the
ascending aorta, aortic arch, descending aorta, thoracic aorta, and abdominal
aorta. In the lower abdomen, the aorta divides into paired common iliac
arteries. Each common iliac artery divides distally into internal and external
iliac arteries. The external iliac artery becomes the femoral artery as it
passes under the inguinal ligament,
a. Femoral artery: Courses through the medial thigh through the femoral
triangle into the adductor canal
b. Deep femoral (profunda femoris): The last branch of the femoral artery
before leaving the femoral triangle
c. Popliteal: When the deep femoral crosses over the medial femur it then
becomes the popliteal and continues to the lower border of the popliteus
where it divides into anterior and posterior tibial (before its bifurcation it
gives off a sural branch which is the only source of blood to the
gastrocnemius)
d. Anterior tibial: Branches off the popliteal artery at the level of the soleal
line, travels into the anterior compartment of the leg, lies between the tibialis
anterior and EDL muscle bellies in the proximal 1/3 of the leg. Immediately
above the the ankle joint the EHL tendon crosses over the anterior tibial
artery and at this level the artery is found between the EHL and EDL. The
anterior tibial artery can terminate as the dorsalis pedis or becomes
insignificant before reaching the ankle joint, and if this happens, the dorsalis
pedis will be absent or arise as a branch of the perforating peroneal artery
i. Branches of anterior tibial artery
• Posterior recurrent tibial
• Anterior recurrent tibial
• Muscular branches (to the tibialis anterior, EDL, EHL,
peroneus tertius, and muscles of the deep posterior
compartment of the leg)
• Anterior medial malleolar (superficial and deep branches)
• Anterior lateral malleolar (transverse portion meets with
branches from perforating peroneal; descending portion
anastomoses with the descending retromalleolar branch of the
peroneal artery)
e. Dorsalis pedis: Begins as it crosses the ankle joint continuous with the
anterior tibia] artery, and gives off branches
i. Branches of the dorsalis pedis
• Medial branches (medial tarsal arteries)
• Lateral branches (artery to the sinus tarsi, lateral tarsal, arcuate,
anterior perforating, 4th dorsal metatarsal, and 1 st dorsal metatarsal artery)
f. Posterior tibial: Branches off the popliteal artery at the level of the soleal
line, remains within the posterior compartment of the leg, runs superficial to
the tibialis posterior proximally and over the FDL distally as it descends into
the medial ankle into the 3rd compartment of the flexor retinaculum, and
bifurcates into medial and lateral plantar arteries while in the 3rd
compartment deep to the muscle belly of the abductor hallucis
i. Branches of the posterior tibial artery
• Circumflex fibular
• Peroneal (gives off muscular branches, perforating branch,
communicating branch, posterior peroneal, anterolateral transverse branch,
collateral branch, and recurrent calcaneal branches)
• Nutrient artery (supplies the tibia)
 NOTE* This is the largest nutrient artery in the body

• Muscular branches (to the soleus, FDL, FHL, and tibialis posterior)
• Communicating artery
• Posterior Medial malleolar
• Medial calcaneal
• Artery of the tarsal canal
g. Medial plantar: Smaller of the 2 terminal branches of the posterior tibial
and gives rise to 2 branches (supplies the abductor hallucis, FDB, 1st dorsal
interosseous)
i. Branches of the medial plantar artery:
• Superficial branch (gives rise to medial marginal plantar artery of the
hallux and the common plantar digital artery)
• Deep branch (divides into a medial and lateral branch)

h. Lateral plantar: Travels into the intermediate compartment laterally and

distally between the quadratus plantae and FDB muscle bellies, and
terminates by connecting the perforating branch of the dorsalis pedis

NOTE' This artery serves as a landmark, separating the 3rd and 4th muscle
layers of the plantar aspect of the foot

i. Branches of the lateral plantar artery:

• 3 posterior/perforating arteries
• 4 plantar metatarsal arteries
• Proper digital arteries

2. The veins: Two sets of veins are found in the lower extremity, superficial
and deep. Most arteries are associated with a pair of deep veins (venae
commitantes). Valves are present in the veins, but are more numerous in the
deep veins. The valves are located at the termination of the great and small
saphenous veins, above and below the knee and ankle joints, and in the leg.
Perforating veins connect superficial veins to deep veins
a. Superficial veins:
i. Dorsal digital veins
ii. Dorsal venous arch
iii. Superficial plantar veins
iv. Greater saphenous vein
v. Lesser saphenous vein
b. Deep veins:
i. Deep dorsal venous network
ii. Deep venous plantar network
iii. Medial and lateral plantar vein
iv. Femoral vein
3. The lymphatics:
a. Lymph nodes: The largest group of lymph nodes are found in the inguinal
region, and are divided into superficial and deep
i. Superficial nodes: There are 2 groups of superficial nodes totalling 1525 in
number
ii. Deep nodes: 1 to 3 in number, found in the femoral canal and occasionally
medial to the femoral vein, where the great saphenous vein drains into it

Myology
1. Osteofascial compartments of the leg
a. Anterior
i. Boundaries: Anterior and laterally by the crural fascia, medially by the tibia,
posteriorly by the fibula. and interosseous membrane
ii. Contents: tibialis anterior, EHL, EDL, peroneus tertius, anterior tibial artery
and veins, deep peroneal nerve
b. Lateral
i. Boundary: Laterally is the crural fascia, posteriorly by the peroneal
septum, medially by the fibula, and anteriorly by the anterior peroneal
septum
ii. Contents: peroneus longus and brevis
c. Posterior (divided into superficial and deep) i. Superficial
• Boundaries: Medially/laterally/posteriorly by the crural fascia, and
anteriorly by the deep transverse intermuscular septum
• Contents: Gastrocnemius, soleus, and plantaris
ii. Deep
• Boundaries: Posteriorly by the deep transverse intermuscular septum,
laterally by the fibula, and medially by the tibia
• Contents: FDL, FDB, tibialis posterior, posterior tibial artery and vein,
and tibial nerve

2. Retinacula of the ankle: Thickened portions of crural fascia which bind

tendons of extrinsic muscles of the foot closely to bone. They are considered
to be superficial ligaments of the ankle
a. Extensor Retinaculum: Is divided into two distinct portions, superior portion
(transverse crural ligament) and inferior portion (cruciate crural ligament)
i. Transverse crural:
• Located entirely on the leg (attached to the tibia and fibula above the
malleoli)
• Separates the tendons of the EDL, the peroneus tertius, and EHL from
each other
ii. Cruciate crural:
• Forms a transverse "Y", with a lateral stem and 2 medial arms
• Lateral stem attaches to the lateral surface of the calcaneus, deep
fascia, and talus
• The superior arm is separated into superficial and deep layers by the
EHL which runs through it
• The inferior arm passes around the medial side of the foot to blend with
the deep fascia of the sole, and attaches to the medial aspect of the plantar
fascia near the tuberosity of the navicular. Medially, the fibers bifurcate to
envelope the muscle belly of the abductor hallucis, forming a tunnel
b. Flexor Retinaculum (lacinate ligament):
i. Forms (in part) the tarsal tunnel
ii. The apex is attached superiorly to the crural fascia and the anteromedial
portion of the medial malleolus. The base it attached inferiorly to the medial
surface of the calcaneus, the medial process of the calcaneal tuberosity, and
tendo Achilles
iii. Contents of the tarsal tunnel:
• 1st (medial compartment): tibialis anterior crosses the medial surface
of the talus and deltoid ligaments
• 2nd compartment: flexor digitorum longus crosses the posteromedial
tubercle of the talus and passes over the medial surface of the
sustentaculum tali
• 3rd compartment: tibial vessels (the nerve runs deep to the artery and
vein)
• 4th (lateral) compartment: flexor hallucis longus grooves the inferior
surface of the sustentaculum tali
c. Peroneal Retinaculum: Divides into superior and inferior surfaces
i. Superior peroneal retinaculum:
• Is quadrilateral in shape
• Splits to enclose the tendons of the peroneus longus and brevis ii.
Inferior peroneal retinaculum;
• Continuous with the main stem of the inferior extensor retinaculum
where it attaches to the lateral surface of the calcaneus
• Some fibers bind to the peroneal tubercle, forming a septum that
separates the 2 peroneal tendons

3. Extrinsic muscles of the foot:

a. Muscles of the anterior compartment:
i. Tibialis anterior:
• Origin: Lateral condyle of the tibia, the upper 2/3 of the lateral surface
of the shaft of the tibia, the interosseous membrane, the deep surface of the
crural fascia, and the intermuscular septum
• Insertion: Into the medial and plantar aspects of the medial cuneiform
(90%) and the medial and plantar aspects of the base of the 1st metatarsal
(10%)
• Vascular supply: Anterior tibial artery
• Innervation: Deep peroneal nerve
• Functions: Statically in dorsiflexion of the foot on the leg, and
dynamically to accelerate and decelerate the foot during gait, assist in
dorsiflexion at toe off, dorsiflex the 1 st ray during swing, resists
plantarflexion of the foot at heel strike, prevents excessive pronation during
swing, and supinates the midtarsal joint around its longitudinal axis prior to
heel strike
ii. Extensor hallucis longus:
• Origin: Anterior surface of the fibula at its middle half (medial to the
origin of the EDL) and the interosseous membrane
• Insertion: Inserts at the base of the distal phalanx of the hallux
• Vascular supply: Anterior tibial
• Innervation: Deep peroneal nerve
• Functions: Statically it dorsiflexes the foot on the leg, extends the
hallux, extends the distal phalanx on the proximal phalanx, and assists in
inverting the foot. Dynamically, during stance it creates a "rigid beam effect"
for the hallux by stabilizing the 1st MTPJ and the IPJ, and during swing it acts
as the strongest dorsiflexor of the foot and accelerates the foot immediately
after toe off
iii. Extensor digitorum longus:
• Origin: Lateral condyle of the tibia, upper 3/4 of the lateral condyle of
the tibia, upper 3/4 of the anterior surface of the tibia, upper lateral part of
the interosseous membrane, deep surface of the crural fascia, and the
anterior peroneal septum
• Insertion: It divides into 4 tendons at various distances proximal to the
ankle joint, and sends a tendon to each lesser toe. Near the metatarsal
heads, each tendon forms a membranous expansion (extensor hood) which
covers the MTPJ dorsally and laterally and receives tendons of insertion from
the lumbricales and interossei muscles to the lesser toes. Tendons to the
2nd, 3rd, and 3rd toes receive tendons from the EDB on their lateral sides.
The EDL tendons to each toe then divide into 3 parts distal to the extensor
hood apparatus at the head of the proximal phalanx
• Vascular supply: Anterior tibial artery
• Innervation: Deep peroneal nerve
• Functions: Statically the EDL dorsiflexes the foot on the leg, extends
the lateral 4 toes, and extends the phalanges of the toes upon each other.
Dynamically, it stabilizes and accelerates the foot during gait, and during the
propulsive period of gait it helps create a "rigid beam effect" in each lesser
toe by assisting the lumbricales in rigidly extending the IPJs during
propulsion. During swing phase it assists in dorsiflexion
iv. Peroneus tertius:
• Origin: From the lower border of the anterior surface of the fibula, and
adjoining portion of the interosseous membrane
• Insertion: On the dorsum of the base of the 5th metatarsal
• Vascular supply: Anterior tibial
• Innervation: Deep peroneal nerve
• Functions: Statically in flexion of the foot on the leg and eversion of the
foot. Dynamically it assists in dorsiflexion of the foot for clearance of the toes
during swing, and helps prevent excessive supination of the foot during
swing
b. Muscles of the lateral compartment:
i. Peroneus longus:
• Origin: From the head and upper 1/2 of the lateral surface of the fibula,
the crural fascia, and the anterior/posterior septa
• Insertion: Posterolateral inferior angle of the base of the 1st metatarsal
(90%) and the adjacent portion of the medial cuneiform (does give a slip that
gives origin to the 1st dorsal interosseous muscle)
• Vascular supply: Anterior tibial and peroneal arteries -Innervation:
Superficial peroneal nerve
• Functions: Statically in plantarflexion of the foot on the ankle, eversion
of the foot. Dynamically it is a stance-phase muscle by stabilizing the base of
the 1st ray against the tarsal bones, stabilizes the 1st metatarsal head
plantarly against the ground, resists the adductory force exerted on the first
ray by the tibialis posterior, and assists (with the peroneus brevis) in
transferring body weight from lateral to medial side of the forefoot during
propulsion
ii. Peroneus brevis:
• Origin: from the lower 2/3 of the lateral surface of the fibula and the
anterior/posterior personeal septa
• Insertion. Lateral aspect of the tuberosity of the 5th metatarsal
• Vascular supply: Peroneal artery
• Innervation: Superficial personeal nerve
• Functions: Statically it plantarflexes the foot on the leg and everts the
foot. Dynamically it is a stance phase muscle by assisting the peroneus
longus in producing an abductory stabilizing force on the foot during
midstance and propulsion, stabilizes the lateral column during midstance
and propulsion, resists supination of the foot and external rotation of the
leg by the calf muscles, provides a pronatory force at the subtalar and
midtarsal joints and assist the peroneus longus in transferring body weight
from the lateral to the medial forefoot
c. Muscles of the posterior compartment (divided into superficial and deep
compartment)
i. Gastrocnemius (superficial):
• Origin: The medial head (larger) of the gastrocnemius from the
posterior portion of the medial condyle of the femur, the lower part of the
supracondylar line, and the posterior aspect of the knee joint capsule. The
lateral head from the posterior portion of the lateral condyle of the femur and
the lower part of the lateral supracondylar line
 NOTE* The tendon of the lateral head of the gastrocnemius may contain a
sesamoid bone (fabella)
The soleus attaches to the medial 2/3 of the deep surface of the tendo-
Achilles The plantaris is absent 7% of the time
The tendo Achilles is 15 cm in length

The gastrocnemius passes across 3 joints (knee, ankle, STJ) The soleus
passes across 2 joints (Knee and ankle) • I
ns
ertion: Fuse with the soleus to form the Achilles tendon
• Vascular supply: Sural branch of the popliteal artery to each head
entering the origin of the muscle
• Innervation: Tibial nerve
• Functions (swing phase): Prevents hyperextension of the knee, assists
in deceleration if the internal rotation of the leg toward the end of contact, to
prevent torque forces from developing in the knee, assists in developing
supination of the STJ during midstance and early propulsion, and flexes the
knee and lifts the heel to initiate propulsion
ii. Soleus (superficial):
• Origin: From the upper 1 /3 of the posterior portion of the fibula,
posterior surface of the fibula, posterior portion of the head of the fibula,
soleal line on the posterior surface of the tibia, and the middle 1 /3 of the
medial border of the tibia
• Vascular supply: Posterior tibial artery, peroneal and sural arteries
-Innervation: Tibial nerve
• Functions (stance phase): Stabilizes the lateral forefoot against the
ground during late contact and midstance, assists in decelerating knee
flexion, assists in decelerating STJ pronation and internal leg rotation at the
end of contact, assists in extending the knee during midstance, assists in
heel lift during propulsion by stopping ankle joint dorsiflexion

iii. Achilles tendon:

• The thickest and strongest tendon in the body in the lower 1 /4 of the
leg. The fibers of the soleus are anterior to those of the gastrocnemius
proximally, and as the tendon passes distally, the gastrocnemius fibers take
a lateral turn to become lateral to the soleus fibers
iv. Plantaris (superficial):
• Origin: From the lateral supracondylar line of the femur, slightly medial
to the lateral head of the gastrocnemius
• Insertion: Into the medial edge of the tendo Achilles -Vascular supply:
Sural arteries
• Innervation: Tibial nerve
• Functions: Statically it flexes the leg on the thigh and plantarflexes the
foot on the leg. Dynamically, it assists the gastrocnemius in its function
during locomotion
v. Flexor digitorum longus (deep):
• Origin: From the posterior surface of the tibia below the popliteal line
and medial to the vertical line and from the fascia of the tibialis posterior
muscle belly
• Insertion: Into the middle of the bases of the distal phalanges of the
lateral 4 toes plantarly
• Vascular Supply: Posterior tibial artery
• Innervation: Tibial nerve
• Functions: Statically, plantarflexing the foot on the leg, flexes the
lateral 4 toes upon their metatarsals, and flexes the phalanges of each toe
upon
each other. Dynamically (stance phase) assists with deceleration of STJ
pronation and internal leg rotation during contact, assists with deceleration of
the forward motion of the tibia during midstance, assists with STJ supination
and external leg rotation during midstance, assists with deceleration of ankle
joint dorsiflexion (contributes to heel lift), maintains stability of the lesser
digits against the ground during propulsion, assists in plantarflexion of the
foot upon the leg during propulsion, and assists the abductor hallucis and FHL
in supination of the MTJ about its oblique axis during early propulsion
vi. Flexor hallucis longus (deep):
• Origin: From the lower 2/3 of the posterolateral portion of the posterior
surface of the fibula, posterior peroneal septum, deep transverse
intermuscular septum
• Insertion: Into the base of the distal phalanx of the hallux, plantarly
• Vascular supply: Peroneal and posterior tibial
• Innervation: Tibial nerve
• Functions: Flexes the hallux at the MTPJ and IPJ, and plantarflexes the
foot on the leg. Dynamically it assists with deceleration of the forward
momentum of the tibia during midstance, assists with STJ supination and
external leg rotation during midstance, assists in deceleration of forward
momentum of the tibia, maintains stability of the hallux against the ground
during propulsion, assists in posterior stabilization of the phalanges on each
other against the 1st metatarsal head, and assists the abductor hallucis and
FDL with supination of the MTJ about its oblique axis
vii. Tibialis posterior (deep):
• Origin: From the posteriomedial surface of the fibula, posterior surface
of the interosseous membrane between the tibia and fibula, posterior surface
of the tibia
• Insertion: Primarily onto the tuberosity of the navicular, however,
insertions reach all the tarsal bones except the talus
• Vascular supply: Sural, peroneal, and posterior tibial arteries
-innervation: Tibial nerve
• Functions: Plantarflexes the foot on the leg and inverts the foot.
Dynamically it is a stance phase muscle that decelerates STJ pronation and
internal rotation of the leg during the contact period, assists with
deceleration of forward momentum of the leg during the contact and
midstance periods, accelerates STJ supination and external rotation of the leg
during midstance, assists in heel lift by decelerating forward motion of the
tibia in ankle joint dorsiflexion
4. Plantar aponeurosis and plantar compartments of the foot:
a. Plantar aponeurosis/Plantar fascia: Is divided in 3 portions (central, lateral,
and medial)
i. Central portion: Is the thickest and strongest, triangular in shape, with its
apex attached to the posteromedial portion of the tuberosity of the
calcaneus. It extends distally and separates into 5 bands. At the level of the
metatarsal heads, each band divides into a deep and superficial process.

f. Superficial transverse metatarsal ligament

b. Plantar
compartments of the foot: Are divided into medial, central and lateral
i. Central compartment: Is the largest and contains 4 fascial spaces
• Contains tendons of the FDL, tibialis posterior, peroneus longus, and
FDB, flexor accessorius, 4 lumbricales, and adductor hallucis
ii. Medial compartment:
• Contains the tendons of insertion of the tibialis posterior and FHL and
muscle bellies of the adductor hallucis and FDB
iii. Lateral compartment:
• Contains the abductor digiti minimi, flexor digiti minimi brevis, and
opponens

5. Intrinsic muscles of the dorsum of the foot:

a. Extensor digitorum brevis:
i. Origin: From the tubercle at the lateral end of the calcaneal sulcus and
cervical ligament
ii. Insertion: To the lateral side of the EDL to toes 2, 3, and 4. It runs
superficial to the dorsalis pedis artery
iii. Vascular supply: Dorsalis pedis (lateral tarsal branch/perforating peroneal)
iv. Innervation: Lateral terminal branch of the deep peroneal and occasionally
the superficial peroneal
v. Functions: Extends toes 2, 3, and 4 and extends the phalanges on each
other. Dynamically it is a stance phase muscle that stabilizes the MTJs
oblique axis in a pronatory direction during propulsion, and stabilizes the
2nd, 3rd, and 4th metatarsals against the lesser tarsus in a posterior
direction, assists
the lumbricales NOTE* There are several aponeurotic structures in the distal forefoot
and EDL in associated with the superficial processes:
extending the a. Natatory ligament: Made up of 6-8 bands of transversely oriented
2nd, 3rd, and aponeurotic tissue deep to the superficial portion of the plantar
4th toes during aponeurosis. It divides the area between the web spaces and dermis
propulsion in the plantar aspect of the metatarsal head region
b. Extensor b. Fasciculus aponeurotica transversum
hallucis c. Sagittal septa
brevis: This is d. Vertical fibers
e. Mooring ligaments
the medial portion of the EDB muscle belly
i. Origin: From the tubercle at the lateral end of the calcaneal sulcus and
cervical ligament
ii. Insertion: Onto the dorsal aspect of the proximal phalanx of the hallux or
the lateral aspect of the EHL tendon
iii. Vascular supply: Dorsalis pedis (lateral tarsal branch perforating peroneal)
iv. innervation: Lateral terminal branch of the deep peroneal, and
occasionally the superficial peroneal
v. Functions. Extends the hallux at the MTPJ and extends the distal
phalanx on the proximal phalanx of the hallux. Dynamically the EHB is a
stance phase muscle that stabilizes the 1st metatatarsal against the lesser
tarsus during midstance and propulsion, and assists in stabilizing the hallux
against the 1st metatarsal in a posterior and abductory direction

6. Intrinsic muscles of the plantar aspect of the foot:

a. First layer (superficial):
i. Abductor hallucis:
• Origin: Medial process of the calcaneal tuberosity, lacinate ligament,
plantar aponeurosis
• Insertion: Mainly to the plantar part of the MTPJ joint capsule and the
medial sesamoid
• Vascular supply: Medial plantar artery
• Innervation: Tibial nerve
• Functions: Statically it flexes and abducts the hallux. Dynamically
(stance phase) it stabilizes the hallux in an abductory direction, assists in
stabilizing the proximal phalanx against the 1st metatarsal head,
plantarflexes the 1st ray, and stabilizes the oblique axis of the MTJ in a
supinatory direction during propulsion against the pronatory force of the
ground reaction
ii. Flexor digitorum brevis:
• Origin: Medial process of the calcaneal tuberosity, and the deep surface
of the plantar aponeurosis
• Insertion: Into the medial and lateral portions of the plantar aspect of
the middle phalanx of each lesser toe

NOTE* Just proximal to the MTPJ the tendon to each toe divides longitudinally
to allow passage of the FDL. It reunites to form a grooved channel for the
FDL under the proximal phalanx, and then divides again at the head of the
proximal phalanx into 2 tendons

• Vascular supply: Medial plantar artery

• Innervation: Medial plantar nerve
• Functions: Statically it flexes the lesser toes and flexes the middle
phalanx upon the proximal phalanx. Dynamically (stance-phase) it stabilizes
the oblique axis of the MTJ in a supinatory direction, stabilizes the 2nd, 3rd,
and 4th rays posteriorly and plantarly, plantarflexes the lesser rays during
propulsion, assists the FDL in maintaining the stability of the lesser digits
iii. Abductor digiti quinti (minimi):
• Origin: Lateral process of the calcaneal tuberosity, plantar surface of
the calcaneus, plantar aponeurosis
• Insertion: The lateral side of the base of the proximal phalanx of the
5th toe plantarly with the tendon of the flexor digiti quinti brevis
• Vascular supply: Lateral plantar artery
• Innervation: Lateral plantar nerve
• Functions: Statically it flexes and abducts the 5th toe. Dynamically
(stance phase) stabilizes the 5th toe posteriorly, plantarly, and in an
abductory direction
b. Second layer:
i. Quadratus plantae: Has 2 heads with the medial head being larger. The
2 heads come together to form a sheet-like 4 sided muscle
• Origin: The medial surface of the calcaneus (lateral head originates
anterior to the lateral process of the calcaneus on its plantar surface from the
long plantar ligament)
• Insertion: Attaches to the lateral aspect of the FDL tendon, before it
divides
• Vascular supply: Lateral plantar artery
• Innervation: Lateral plantar nerve
• Functions: Statically it aids in flexing the 4 lateral toes by assisting the
FDL. Dynamically it stabilizes the oblique axis of the MTJ in a supinatory
direction during midstance and propulsion, stabilizes the tendons of the FDL,
and stabilizes the lesser metatarsals

ii. Lumbricals: Are numbered 1-4 from medial to lateral

• Origin: 1 st from the medial margin of the FDL to the 2nd toe. 2nd from
adjacent sides of of the 1st and 2nd FDL tendons. 3rd from adjacent sides of
2nd and 3rd FDL tendons, 4th from adjacent sides of 3rd and 4th FDL
tendons
Insertion: Into the medial aspect of middle of proximal phalanges
• Vascular supply: Plantar metatarsal artery
• Innervation: 1st lumbrical L5 and S1 (medial plantar nerve), the rest via
roots S1 and S2
• Functions: Statically they function to flex the 4 lesser toes, adduct the
lesser toes toward the hallux and extend the phalanges of each toe.
Dynamically they function to extend the IPJs of each lesser toe, assist in
stabilizing the proximal phalanx of each lesser toe against the ground

NOTE* All intrinsic muscles of the 2nd layer are related to tendons of the FDL
c. Third which pass through it
layer:
i. Flexor hallucis brevis: Has a "Y" shaped configuration
• Origin: Originates from the medial aspect of the plantar surface of the
cuboid (stem), the lateral and plantar aspects of the 3rd cuneiform (lateral
arm), peroneus longus sheath, (lateral arm), tibialis posterior to the 3rd
cuneiform and cuboid (lateral arm), and tendinous slips of the tibialis
posterior to the metatarsal bases (medial arm)
• Insertion: 2 heads of insertion into the plantar plate of the 1st MTPJ and
sesamoid area, then passes forward to insert with the tendon of the abductor
hallucis into the base of the proximal phalanx
• Vascular supply: 1st plantar metatarsal artery
• Innervation: Medial plantar nerve
• Functions: Statically it aids the hallux in flexion. Dynamically (stance
phase) it stabilizes the base of the proximal phalanx of the hallux against the
ground during propulsion, assists in stabilizing the entire hallux against the
ground, and assists in stabilizing the 1st, 2nd, and 3rd metatarsals at the
metatarsocuneiform joints during propulsion
ii. Adductor hallucis: This consists of 2 different muscle bellies of origin
(oblique and transverse heads)
• Origin: Oblique head from the medial sides of the shafts and bases of
metatarsals 2-4, adjacent portions of associated cuneiforms, and peroneal
sheath. The transverse head originates from the deep transverse metatarsal
ligaments, plantar plates, joint capsules, and plantar metatarsal ligaments 3-
5 MTPJs
• Insertion: Both heads insert by a common tendon which inserts into a
bony prominence on the inferolateral aspect of the base of the proximal
phalanx of the hallux with the tendon of the lateral head of the FHB
• Vascular supply: 1 st plantar metatarsal artery
• Innervation: Deep branch of the lateral plantar nerve
• Functions: Statically flexes hallux. Dynamically the oblique head is a
stance-phase muscle that stabilizes the hallux in an adductory direction as
well as a posterior direction against the metatarsal head and assists in
stabilizing the proximal phalanx against the ground during propulsion. The
transverse head is a stance-phase muscle that prevents elongation of the
deep transverse metatarsal ligament, and transverse stability to the forefoot
at the MTPJs during propulsion
iii. Flexor digiti quinti (minimi) brevis:
• Origin: From the base of the shaft of the 5th metatarsal, crest of the
cuboid, and peroneal sheath
• Insertion: To the base of the proximal phalanx of the 5th toe laterally
and plantar (along with the tendon of the abductor digiti quinti)
• Vascular supply: Lateral plantar artery
• Innervation: Superficial branch of the lateral plantar nerve
• Functions: Statically it abducts and flexes the 5th toe. Dynamically it
functions as an interosseous muscle during gait
d. Fourth layer:
i. Plantar interossei: Three in number
• Origin: 1 st from the base and medial surface of the shaft of the 3rd
metatarsal. 2nd medial surface of the shaft and plantar surface of the base of
the 4th metatarsal. 3rd from the plantar aspect of the base and medial
surface of the shaft of the 5th metatarsal
• Insertion: 1st inserts into the 3rd toe medially near the base of the
proximal phalanx, and the medial side of the 3rd MTPJ capsule. 2nd is into
the 4th toe medially near the base of the proximal phalanx, and the medial
side of the 4th MTPJ capsule. 3rd inserts medially into the 5th toe near the
base of the proximal phalanx, and the medial side of the 5th MTPJ capsule
• Vascular supply: 2nd, 3rd, and 4th plantar metatarsal arteries
• Innervation: Lateral plantar nerve
• Functions: Statically the plantar interossei aid in flexing the toes into
which they are inserted and aid in extension of the IPJs. Dynamically they
draw the toes medially toward the 2nd digit

ii. Dorsal interossei: Four in number

• Origin: 1st from the adjacent surfaces of the first and second
metatarsals. 2nd from the adjacent surfaces of the second and third
metatarsals. 3rd from the adjacent surfaces of the third and fourth
metatarsals. 4th from the adjacent surfaces of the fourth and fifth
metatarsals
• Insertion: 1st inserts into the membranous expansion of the EDL to the
2nd toe and the medial side of the base of the proximal phalanx of the 2nd
toe. 3rd into the membranous expansion of the EDL to the 3rd toe and the
lateral side of the base of the proximal phalanx to the 3rd toe. 4th into the
the membranous expansion of the EDL to the 4th toe, and the lateral side of
the base of the proximal phalanx of the 4th toe
• Vascular supply: 2nd, 3rd, and 4th plantar metatarsal arteries
• Innervation: Lateral plantar nerves (superficial and deep)
• Functions: Statically they aid in flexing the toe to which they insert and
in extending the IPJs. Dynamically these are stance-phase muscles that
stabilize the bases of the proximal phalanges posteriorly and transversely
against their metatarsal heads

7. Extensor hood expansion:

a. It is a membranous sheet covering each lesser toe from the MTPJ to (and
including) the distal phalangeal joint
b. It receives contributions from the:
i. EDL tendon
ii. Plantar and dorsal interossei tendons
iii. Tendons of the lumbricales
iv. EDB tendon (toes 2-4)
v. Deep process of the plantar aponeurosis
c. The hood apparatus provides a means for the EDL to extend the proximal
phalanx without having a direct connection to it by controlling the actions of
the interossei and lumbricales muscles
d. The hood apparatus is made up of 2 parts that are continuous with each
other, the sling and wing
e. The sling is more proximal, and the wing is more distal
f. The action of the lumbricales and interossei of the phalanges is intergrated
with that of the EDL by the extensor apparatus attachments

Arthrology
1. Tibiofibular joints: The tibia and fibula are joined in 3 areas proximal,
distal, and crural interosseous

a. Proximal tibiofibular joint: A plane synovial joint between the facet on the
medial aspect of the head of the fibula and the fibula facet on the lateral
condyle of the tibia
i. Anterior superior tibiofibular ligament
ii. Posterior superior tibiofibular ligament
b. Distal tibiofibular joint: A syndesmosis between the distal ends of the tibia
and fibula
i. Interosseous tibiofibular ligament
ii. Anterior inferior tibiofibular ligament
iii. Posterior inferior tibiofibular ligament

c. Crural interosseous membrane (middle tibiofibular joint): A sheet of fibrous

connective tissue between the interosseous borders of the tibia and fibula
d. Functional anatomy of the tibiofibular joint:
i. Motion is limited to slight rotation and gliding
ii. In ankle dorsiflexion, the talus is forced into the ankle mortise, separating
the 2 bones (adding stability). Distal separation is limited by the fibrous
syndesmosis of the distal joint and the crural interosseous membrane
2. Ankle joint (talocrural): A modified ginglymus or hinged synovial joint.
In addition to dorsiflexion/plantarflexion, a small amount of
abduction/adduction as well as eversion/inversion
a. Articular surfaces (superior concavity): The ankle mortise
i. Distal end of the tibia (tibial plafond): wider anteriorly (produces stability in
stance)
ii. Comma shaped facet on the lateral surface of the medial malleolus
iii. Triangular shaped facet on the medial surface of the lateral malleolus iv
Anterior tibiofibular ligament
b. Medial collateral ligaments (deltoid): Fans out into one deep and 3
superficial portions, with attachments to the talus, calcaneus, and navicular
i. Anterior tibiofibular ligament: Deepest
ii. Posterior tibiofibular ligament
iii. Tibiocalcaneal ligament: Blends with the spring ligament
iv. Tibionavicular ligament
c. Lateral collateral ligaments: 3 subdivisions
i. Anterior talofibular ligament: Intracapsular, blends with the ankle joint
anteriorly, shortest lateral ligament, deep
ii. Posterior talofibular ligament: Strongest, intracapsular but extrasynovial
iii. Calcaneofibular ligament: Extracapsular, found deep to the tendons of the
peroneals

NOTE* This ligament crosses the ankle and STJ as does the tibiocalcaneal
ligament
d. Fibrous capsule: Surrounds the ankle joint and is attached to the margins
of the articular surfaces
e. Synovial capsular membrane:
i.Closely attached to the fibrous capsular membrane medially and laterally
ii. Bulges are seen at the anterior tibiofibular ligament and parts of the lateral
ligament
iii. Synovial membrane is exposed near the medial malleolus
iv. Loose fold of synovial membrane is present in the ankle mortise between
the articulation of the lateral malleolus and inferior surface of the tibia
(allows for accommodation of the talar dome) f. Functional anatomy:
i. Oblique axis of motion running from posteroinferolaterally to
anterosuperomedially (pronatory/supinatory)
ii. The axis changes as the foot moves with dorsiflexion and plantarflexion

3. Subtalar joint (anatomic): A modified ginglymus joint

NOTE* The "anatomic" STJ is defined as the synovial articulation between the
posterior talar facet on the superior surface of the calcaneus and the
posterior calcaneal facet on the inferior surface on the body of the talus. The
'functional" STJ includes the middle and anterior facets
The anterior and middle facets of the calcaneus are part of the
talocalcaneonavicular, a separate Synovial joint.
a. Articular areas: The posterior facets are roughly triangular in shape. The
articular surface of the the talus is concave, and the calcaneal surface is
convex alond its longitudinal axis
b. Sinus tarsi: Formed by the articulation of the sulcus calcanei between the
posterior and and anterior-middle facets of the calcaneus and the sulcus tali
on the inferior surface of the talar neck. It is wider laterally
c. Fibrous capsule: Completely surrounds the joint and reinforced by capsular
ligaments
d. Capsular ligaments:
i. Posterior calcaneal ligament: "Y" shaped. Medial band forms a roof over the
groove for the FHL tendon
ii. Lateral talocalcaneal ligament
iii. Medial talocalcaneal ligament
iv. Anterior talocalcaneal ligament
v. Interosseous talocalcaneal ligament (ligament of the tarsal canal): Located
within the tarsal canal and strengthens the STJ posteriorly
vi. Cervical ligament: Found laterally in the sinus tarsi, and resists supination
of the STJ
e. Functional anatomy:
• Most important STJ supinators are the tibialis anterior and tibialis
posterior
• Most important pronators are the peroneus longus and peroneus brevis
• The long axis of the posterior talar facet of the calcaneus is at an angle
of about 40° to the long axis to the foot

4. Talocalcaneonavicular joint: The head of the talus fits into a socket

formed by the posterior articular surface of the navicular and the anterior
and middle talar articular facets of the calcaneus, as well as the plantar
calcaneonavicular ligament
a. Classification: A modified condylar joint (capable of gliding and rotatory
motion)
b. Articular surfaces:
i. Head of talus:
• Convex in all directions
ii. Acetabulum pedis (joint socket):
• Anteroinferior portion: Concave in all directions, and formed by the
posterior surface of the navicular
• Posterior portion: Formed by the anterior and middle articular facets of
the calcaneus
• Inferomedial portion: Formed by the plantar calcaneonavicular ligament

NOTE* The articular area of the talar head is greater than the socket, and as
a result, in normal anatomic position, the head protrudes slightly dorsally at
the joint

c. Capsular ligaments:
i. Dorsal talonavicular ligament
ii. Plantar calcaneonavicular ligament (spring): Important in supporting the
talar head
iii. Calcaneonavicular portion of the bifurcate ligament: "Y" shaped with the
stem attached to the calcaneus and one arm attached to the cuboid and the
other arm to the navicular
d. Synovial membrane: Lines the fibrous capsule
e. Functional anatomy:
i. Some gliding and rotational movements are possible, but the TCN joint
cannot act independently
ii. Any motion at the STJ causes motion in the TCN joint. Additionally, motion
between the talus and navicular also involves the C-C joint

5. Calcaneocuboid joint: Formed by the articulation of the posterior

surface of the cuboid and the anterior surface of the calcaneus
a. Classification: A saddle-shaped synovial joint
b. Fibrous capsule: Surrounds the entire joint and has 3 capsular ligaments
i. Dorsal calcaneonavicular ligament
ii. Lateral calcaneocuboid ligament
iii. Calcaneocuboid portion of the bifurcate ligament
c. Extracapsular ligaments:
i. Long plantar ligament (long calcaneocuboid):
• Superficial and deep fibers
• Longest ligament in the foot
• Posterior fibers attached to plantar surface of the calcaneus and runs
distally to bases of metatarsals 2-5
d. Synovial capsule: Lines the entire joint
e. Functional anatomy: Has two axes of rotation
i. One axis through the calcaneal process
ii. One axis through the head of the talus
• Pronation results in the plantar, dorsal, and lateral ligaments being taut
• Supination results in the opposite

6. Great tarsal joint: Made up of the following joints

a. Cuboideonavicular joint:
i. Classification: Syndesmosis or planar synovial
ii. Fibrous capsule: Present only when a synovial joint is present. Has 3
capsular ligaments
• Dorsal cuboideonavicular
• Interosseous cuboideonavicular
• Plantar cuboideonavicular
i. Function: Very limited motion, but the motion that does occur is with
pronation/supination of the STJ
b. Cuneonavicular joint:
i. Classification: Planar in configuration, with a slight convexity in the
navicular
ii. Fibrous capsule: Continuous with all 3 navicular facets, but absent
laterally. Has 3 main capsular ligaments
• Dorsal cuneonavicular
• Medial cuneonavicular
• Plantar cuneonavicular (divided into 3 ligaments)
c. Intercuneiform joints: Forms part of the transverse pedal arch, with the
intermediate cuneiform being the highest point of the arch
i. Classification: Planar synovial
ii. Articular areas:
• Medial intercuneiform joint
• Lateral intercuneiform joint
• Cuneocuboid joint
iii. Fibrous capsule: Blends with the cuneonavicular capsule
d. Cuneocuboid joint
e. Tarsometatarsal joints (2nd and 3rd)
f. Intermetatarsal joints (bases of 2nd and 3rd)

7. Tarsometatarsal joints (LisFranc's joint): Formed by the articulations

between the anterior surfaces of the cuneiforms and cuboid proximally and
posterior surfaces of the metatarsals distally. The 2nd metatarsal base is
recessed proximally for added stability and restricted motion.
a. Classification: Has 3 synovial joints
i. Medial tarsometatarsal joint: Between the base of the 1st metatarsal and
medial cuneiform
ii. Intermediate tarsometatarsal joint: Between the base of the 2nd and 3rd
metatarsals and intermediate and lateral cuneiforms
iii. Lateral tarsometatarsal joint: Between the bases of the 4th and 5th
metatarsals and cuboid
b. Fibrous capsule: Each T-M synovial joint has its own capsule
c. Capsular ligaments:
i. Dorsal tarsometatarsal ligaments
ii. Plantar tarsometatarsal ligaments
d. Inferior surface of the medial cuneiform to the base of the 1st metatarsal
i. Interosseous tarsometatarsal ligaments (attach the cuneiforms or cuboid to
the metatarsal bases)
• Medial interosseous ligament (LisFranc's ligament): Strongest, runs
from the lateral surface of the medial cuneiform to medial surface of the 2nd
metatarsal base, and is important for stability of the T-M joint
• Intermediate interosseous ligament (2nd)
• Lateral interosseous ligament (3rd)
e. Function: Slight gliding motion of the lesser metatarsal on their adjacent
tarsal bones